Does Skin Color Affect Lyme Disease Diagnosis?
So, how prepared are medical students to properly diagnose patients of all races and ethnicities? Do they have the diagnostic ability and confidence to recognize conditions such as Lyme disease in individuals with non-white skin?
In the study
“The impact of patient skin colour on diagnostic ability and confidence of medical students,”
Dodd et al.1 examined whether medical students’ diagnostic accuracy and confidence varied depending on a patient’s skin color.
An online quiz using clinical photographs helped evaluate students’ diagnostic abilities and confidence. Case vignettes were also used to better understand the students’ clinical reasoning processes.
Study Design
The authors presented an online quiz to 185 medical students. The quiz contained 24 medical photographs representing 12 clinical conditions relevant to the students’ curriculum:
- Shingles
- Kawasaki disease
- Cellulitis
- Pityriasis versicolor
- Lyme disease
- Central cyanosis
- Eczema
- Urticaria
- Chickenpox
- Meningococcal disease
- Jaundice
- Henoch-Schönlein purpura
Students were shown two images for each condition: one from a patient with white skin (WS) and another from a patient with non-white skin (NWS). The NWS images included individuals from Black and Asian racial groups with varying skin tones.
Diagnostic Differences by Skin Color
Students were significantly more likely to diagnose several conditions correctly on white skin compared to non-white skin.
The investigators reported that:
Students were significantly more likely to accurately diagnose five of the 12 clinical presentations — shingles, cellulitis, Lyme disease, eczema and meningococcal disease — on patients with white skin compared to those with non-white skin.
Why Lyme Disease May Be Missed
The diagnostic challenges became clearer when reviewing participants’ comments.
“… I feel like on darker skin tones, sometimes it’s the opposite, and sometimes you just don’t notice the erythema migrans rash …”
“So, I think the lack of representation of darker skin in the textbooks can be detrimental when it comes to education and understanding what rashes may look like on darker skin tones.”
“… we often only see images of white Caucasian people with skin conditions in textbooks and online resources.”
Improving Medical Training
The participants suggested several ways medical education could improve diagnostic confidence across skin tones.
- Show the same condition on both lighter and darker skin tones
- Include a wider range of skin color representation in textbooks
- Provide more clinical experience with diverse patient populations
- Encourage closer attention to skin findings in darker skin tones
“I think every time I’m shown a diagnosis on a lighter skin tone, if I was shown the exact same diagnosis on a darker skin tone it would be helpful.”
Study Conclusions
The authors concluded that students were:
“significantly more capable of diagnosing several common clinical presentations (shingles, cellulitis, Lyme disease, eczema and meningococcal disease) on patients with white skin compared to those with non-white skin.”
The authors noted limitations to their study, including a relatively small and non-representative sample.
They also highlighted the lack of available medical images representing diverse skin tones, which itself reflects the educational gap students face.
The study was designed to explore the potential impact of unconscious racial bias and gaps in medical education on clinical diagnosis.
Related Articles
Can race affect the diagnosis and treatment of Lyme disease?
Black children more likely to be diagnosed later with Lyme disease
Lower socioeconomic status: a risk factor for disseminated Lyme disease
References:
- Dodd RV, Rafi D, Stackhouse AA, et al. The impact of patient skin colour on diagnostic ability and confidence of medical students. Adv Health Sci Educ Theory Pract. 2023. doi:10.1007/s10459-022-10196-6
Dr. Daniel Cameron, MD, MPH
Lyme disease clinician with over 30 years of experience and past president of ILADS.
Symptoms • Testing • Coinfections • Recovery • Pediatric • Prevention
Hello Dr. Cameron. Belated thank you for returning my phone call in 2008! We were in Canada, you provided me with much needed validation that tx was going to be difficult(impossible let’s be honest here) there. Son was 8. You could not treat kids. Well he’s 25 now and has CFS/ME but will not follow LLMD and decided to disbelieve Dr. M. and/or TBD dx. VEry sad and difficult. Anyhow, I am a Simulation content expert and skin color and medical diagnostics has been a concern of mine for many years. At the 2010 ILADs conference I spoke to the young woman who was in Under Our Skin about tick attachment and darker skin. She related that one of her best friends was dark skinned and had a tick attachment but thought it was a skin tag! Having lived upstate in Ulster County c. 1995-2007 I have vast experience of tick attachment and how pernicious this can be. I am a fair skinned woman who identifies as African American, and my training is in Medical Anthro (Harvard and UC). In Simulation we train medical professionals in diagnostics and many other things – and the fact that every time we had to use a clue card to present to the student we could not find one that featured any skin tone but “white” was an eternal frustration. I would like to forward your info to a young doctor in England who has started a website and programs to address this horrendous oversight in Medical Training. I will also try to get you his info, do you know it? Malone at “HUTANO”
I posted of blog of this article on skin color to encourage debate on race even with Lyme disease.
Excellent article. We miss the EM rashes in pigmented individuals too often. They might have increased darkening (not reddening) at their EM sites, as documented well in the Mass Dept of Health brochure and other pamphlets for the public. Katherine Murray Leisure, MD, Plymouth MA. USA.
I agree